Biopsies of focal lesions in multiple myeloma is commonly performed. CT-guided biopsy of MR or PET detected focal lesions is a safe technique that can provide important cytogenetic information in a significant number of patients with multiple myeloma not identified during random marrow sampling.

Cytogenetic abnormalities, especially chromosome 13 deletion, are high-risk factors for multiple myeloma. Attaining the highest detection rates of cytogenetic abnormalities is important to provide accurate prognostic information to the referring oncologist. A study done at UAMS used CT-guided percutaneous fine-needle aspiration bone biopsy (CT-guided FNA) of MR-detected focal lesions in patients with multiple myeloma to increase identification of abnormal cytogenetics.

CT-FNA identified abnormal karyotypes in approximately 21% of samples in each treatment protocol. This was similar to the number identified by RMS. More significantly, CT-FNA discovered unsuspected cytogenetic abnormalities missed on RMS in nearly 10% of patients in the TT II trial and 20% of those in the DTPACE trial. These findings include new identification of chromosome 13 deletion in 5% of the patients in the TT II group and 10% of those in the DTPACE group. This information altered the prognosis and treatment in patients with multiple myeloma. Further therapy with a non-myeloablative matched mini-allotransplant was considered in this group of patients.

CT-FNA should not be performed without appropriate imaging evaluation. Although nearly all patients will have lytic lesions in the spine or pelvis by CT, morphologic determination of which lesion will most likely yield cells with abnormal cytogenetics is very difficult. MR identification of focal lesions has been extensively studied in multiple myeloma. In our patients, we selected focal lesions that were detected on STIR images that corresponded to a lytic lesion on the CT scans, as these may indicate sites with increased plasma cells, more aggressive cells, or different clonal elements. Complications are least likely to occur when biopsies are done in the pelvis. The biopsy site was selected on the basis of the most accessible lesion in the pelvis, then in the lumbar spine, and last in the thoracic spine. Other selection criteria included the development of a new lesion or an increase in size of a previously identified lesion when compared with previous MR studies. Lesions occurring in a known radiation therapy site in the pelvis or spine were excluded. Other exclusion criteria were recent surgery, proximity of the surgical and biopsy sites, presence of surgical hardware at the biopsy site, and presence of prosthetic devices, such as braces and ostomy bags.

CT-Guided Biopsy

A biopsy was performed on this 65 year-old male who was diagnosed with multiple myeloma. A needle was placed and the needle injected through the pedicle into the vertebral body (lumbar spine) is demonstrated. The needle was advanced into the lytic lesion using CT guidance. CT guidance improves accuracy and provides precise guidance.

Reference
Avva R, VanHemert RL, Barlogie B, Munshi N, Angtuaco EJ: CT-guided Biopsy of Focal Lesions in Patients with Multiple Myeloma May Reveal New and More Aggressive Cytogenetic Abnormalities. AJNR 22:781-785, April 2001.

Nursing Staff
Mrs. Leta Peterson is a neuroradiology nurse who is involved in scheduling the biopsies primarily for multiple myeloma patients. Call 686-5751 for further information.

Physicians
Dr. Rudy vanHemert, Dr. Eren Erdem, Dr. Vivek Gupta, Dr. Rajesh Sethi, Dr. Muhammad Yousaf, and Dr. Edgardo Angtuaco, are neuroradiologists and neurointerventional radiologists who perform the vertebral body biopsies and vertebroplasties in patients with multiple myeloma. They are involved in the clinical care and research of the multiple myeloma patients. The UAMS Radiology faculty information page contains further information about these physicians.

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